NCC223890_FRO Submitted_20221129

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/or fax
information unavailable, place N/A in the blank.)
Part A.
1. Project Name Sandy Hollow
2. Location of land -disturbing activity: County Onslow City or Township Jacksonville
Highway[Street Jubilance Latitude 34.8083 Longitude-77.5171
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (Including off -site borrow and waste areas):__ 24.6 _ _
6. Amount of fee enclosed: $_ 2,500 The application fee of sioo.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$5565).
7. Has an erosion and sediment control plan been filed? Yes No X Enclosed_ X _
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Elijah Morton E-mail Address [e-mail]
Telephone [phone] Cell # Fax # _
9. Landowner(s) of Record (attach accompanied page to list additional owners):
South State Development, LLC
[phone]
Name
Telephone Fax Number
121 Garnet Lane
121 Garnet Lane
Current Mailing Address
Current Street Address
Jacksonville, NC 28540
Jacksonville NC 28540
city State Zip
City State Zip
10. Deed Book No. 5730- - _ __ Page No.-___
26 Provide a copy of the most current deed.
Part B.
1. Company (ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties
on an attached sheet.) if the company or firm is a sole
proprietorship the name of the owner or manager may
be listed as the financially responsible party.
South State Development, LLC
[e-mail]
Name
E-mail Address
121 Garnet Lane
121 Garnet Lane
Current Mailing Address
Current Street Address
Jacksonville, NC 28540
Jacksonville, NC 28540
city State Zip
City State Zip

Telephone___ _ Fax Number.
2. (a) If the Financially Responsible Party Is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State
Fax Number
Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certfflcate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City -- — State Zip City
Telephone____-.
Fax Number
State ZIP
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an Individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute Instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Elijah Morton Managing Member
;Siature
nt me Title or Authority
�_ q-�-)-
Date
I, J t? SS t CGx. LAW CM e , a Notary Public of the County of _ Call o s L)
State of North Carolina, hereby certify that - - I r ^ h OC�'� _ appeared
personally before me this day and being duly sworrh acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this OL1 day of S , 20 a -a
JESSICA LAWRENCE- Not
Seal Notary Public
North Carolina My commission expires (p —
Onslow County